Provider Demographics
NPI:1720004146
Name:WYATT, RHONDA (MD)
Entity Type:Individual
Prefix:
First Name:RHONDA
Middle Name:
Last Name:WYATT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 492080
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96049-2080
Mailing Address - Country:US
Mailing Address - Phone:530-241-0473
Mailing Address - Fax:530-241-5377
Practice Address - Street 1:2020 COURT ST
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-1822
Practice Address - Country:US
Practice Address - Phone:530-243-1236
Practice Address - Fax:530-243-8502
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG762742085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G762742Medicaid
CAE42186Medicare UPIN
CA00G762742Medicaid